2015_0925 IRRIGATION�_ DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier far recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) ,., ►�
MAILING ADDRESS: ���03 ��°i�`�'�e�' �'r P'P�� � �x ���f�
CONTACT PERSON/PHONE: bu�� �S IY�p�i�a 5 Z�y - ��6'"90'�O
LOCATION OF SERVICE: Z�O S�u �-' crn �� �'n�� ��` •
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle -�Reduced Pressure Principle-Detector
��oubleCheckValve iJDouble Check-Detector
�PressureVacuumBreaker i 'Spill-Resistant Pressure Vacuum Breaker
L�, r�
Manufacturer �a"��� Model Number ��� m � Q� Size Z
Located At �� 'V"� 5���sI Serial Number P �0�� �
� Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check�Valve
1 st Check 2nd Check
Held at ( �`� psid Held at ��� psid Opened at Opened at Held at
Initial Test Closed Tightf� Closed Tight '�9 psid psid psid
Leakedl� I Leakedl�'� Did not open f I Did not open � 1 Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight�1 ClosedTight�;_J psid psid psid
Test gauge used: Make/Model ���raLO `C�' Z�d �K SN. 7���'��
Date Tested for Accuracy: � �� �s
Remarks:
The above is certified to be true at the time of testing.
FirmName� e�� -�'i-sb' Firm Address r3b3�� Ier �r � eI� ��
Certified Tester(print) �V�d �C'x��Q''� Certified Tester(signature) �
Firm Phone# ��`[ �-6�b� ���o Cert.Tester No. fJl" p��p�� Date zJ ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy Yellow-Customer Copy Pink-Tester's Copy